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Self-enhancing Confabulation: Revisiting the

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Self-enhancing Confabulation: Revisiting the
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ISSN: 1355-4795 print / 1465-3656 online
DOI: 10.1080/13554790601160566

Self-enhancing Confabulation: Revisiting the

NNCS

Motivational Hypothesis

AIKATERINI FOTOPOULOU1, MARTIN CONWAY2, PHILIPPA GRIFFITHS3, DANIEL BIRCHALL4 and STEPHEN TYRER5
SELF-ENHANCING CONFABULATION

1
Institute of Psychiatry, King’s College London, London, UK
2
Institute of Psychological Sciences, University of Leeds, Leeds, UK
3
Jennie Heppell Service, Northgate & Prudhoe NHS Trust, UK
4
Neuroradiology Department, Regional Neuroscience Centre, Newcastle-upon-Tyne, UK
5
Psychiatry Department, University of Newcastle-upon-Tyne, Newcastle-upon-Tyne, UK

We report a patient who developed spontaneous confabulation following surgical clipping of an anterior communicating artery aneurysm.
An autobiographical memory test was used to measure the emotional valence of the patient’s self-representations in true and false
memories. We found that his confabulations included significantly more positive self-representations than his true memories and that the
overall valence of his confabulations was more positive than that of his true memories and than that of the memories of five healthy control
participants of the same age and educational attainment. It is proposed that while cognitive dysfunction may explain how confabulations are
formed, emotional factors may explain which specific confabulations are constructed.

Keywords: Emotion, valence, ACoA, memory, amnesia, prefrontal cortex

Introduction
The term confabulation refers to the production of fabricated,
distorted or misinterpreted memories about oneself or the
world, without the conscious intention to deceive (see also
Feinberg and Giacino, 1997). Confabulations can range from
simple and provoked memory distortions to spontaneous and
bizarre fabrications of false autobiographical events (see
DeLuca, 2000, for review). Theoretical explanations of con-
fabulation fall within two main traditions: theories that view
confabulation as a psychogenic phenomenon and theories
that view it as the result of cognitive dysfunction (see Deluca,
2000; Johnson et al., 2000, for reviews). In the first category,
confabulation is explained as a product of the psychological
need to “fill in” embarrassing memory gaps, satisfy the sug-
gestions of the examiner, or deny the painful reality of brain
damage (see Berlyne, 1972; Whitlock, 1981; Weinstein,
1996, for reviews). By contrast, neurocognitive models
explain confabulation as a cognitive inability to: (a) retrieve
memories in an organised and goal-oriented way (e.g.
Burgess and Shallice, 1996; Moscovitch, 1989); (b) distin-
guish between memories that pertain to on-going reality and
those that do not (e.g. Dalla Barba et al., 1997; Schnider,
2003); or (c) distinguish between mental representations of
various sources (Johnson et al., 2000).
More recently, we have put forward a third approach
which proposes that both classes of explanation may be
needed to provide a full account of the mechanism of confab-
ulation and the nature of the resulting confabulated memories
(see Conway and Tacchi, 1996; Fotopoulou et al., 2004;
Solms, 2000). We propose that cognitive dysfunction may
explain how confabulations are formed, while exaggerated
motivational influences may explain which specific false
memories are constructed and why. In psychiatry there is a
long history of similar distinctions between the form and con-
tent of false beliefs (Jaspers, 1913; see Kopelman, 1997;
McKay et al., 2005, for discussions). This motivational view
is hitherto supported by either anecdotal descriptions (Conway
and Tacchi, 1996; Solms, 2000), or measurements of con-
fabulations produced spontaneously and thus with partial
experimental control (e.g. Fotopoulou et al., 2004).
In the present study we aim to investigate the valence of
confabulation under greater experimental control in a patient
who developed extreme and spontaneous confabulation

We thank patient LH and his family for their participation. The study was facilitated by a grant from the British Economic and Social
Sciences Research Council and the Medical Research Council to Dr Fotopoulou, as well as by an award from the Neuro-psychoanalysis
Foundation to Dr Fotopoulou.
Address correspondence to Dr Aikaterini Fotopoulou, Academic Unit of Psychiatry, St. Thomas’s Hospital, South Wing, Block 8,
London, SE1 7EH, UK. Tel. +44 207 1880204. Fax: +44 207 6330061. E-mail: a.fotopoulou@iop.ac.uk

© 2007 Psychology Press, an imprint of the Taylor & Francis Group, an Informa business
 SELF-ENHANCING CONFABULATION 7
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following surgical clipping of an anterior communicating
artery (ACoA) aneurysm. We used a method deriving from
studies on autobiographical memory that can elicit memories
of specific self-defining value (e.g. McAdams, 2001; Pillemer,
2001). Using this method, we compared the emotional
valence of the patient’s true memories and confabulations,
and the emotional valence of control participants’ true memo-
ries. Our main hypothesis was that the false memories con-
structed by our patient would portray himself in more
positive terms than his real memories about himself. A fur-
ther aim was to establish whether these confabulations were
the outcome of an intentional tendency to fill in memory gaps
and/or satisfy the suggestions of the examiner (see Berlyne,
1972; Whitlock, 1981, for reviews), or whether they were
genuine attempts to remember one’s past and convey a corre-
sponding self-representation.
Case report
LH was a 60-year-old, right-handed man with no significant
previous medical or psychiatric history. He was a medical
equipment salesman and local managing director of his firm.
LH was travelling on business when he was urgently admitted
to hospital with severe headache, nausea and vomiting. A CT
angiographic investigation confirmed the presence of a small
saccular aneurysm at the junction of the A1 and A2 segments
of the left anterior cerebral artery which also revealed sub-
arachnoid haemorrhage in the adjacent subarachnoid space and
in the medial right frontal lobe. He underwent craniotomy and
clipping of the anterior communicating artery (ACoA) aneu-
rysm the following day. A post-operative cerebral angiogram
confirmed satisfactory clipping. Figure 1 shows a CT angio-
graphic study performed 10 days post-surgery. There was a
sizeable extra cranial haematoma with evidence of recent
haemorrhage and the placement of an aneurysm clip in the left
paraclinoid region. There was a large acute infarction within
the left frontal lobe, including both the dorsolateral and ventro-
medial prefrontal cortex. In addition, there was a smaller hae-
matoma within the posterior aspect of the right frontal lobe and
a small residual haematoma in the depth of the anterior inter-
hemispheric fissure/septum pellucidum. Residual subarach-
noid blood was noted within the mid line frontal sulci and over
the convexity mainly on the left. There was also a small
amount of blood in the occipital horns. Ventricles were mildly
prominent. There was soft tissue swelling within the scalp tis-
sues overlying the left frontal craniotomy.
On clinical examination 4 months post-surgery, LH’s amne-
sia, confabulation and dysexecutive syndrome were immedi-
ately evident. LH was very talkative, hyperactive and often
verbally disinhibited. He could rarely remain within the limits
of given conversational topics. His answers had an almost met-
aphorical quality, in that he provided a relevant answer but this
was set in an irrelevant context. For example, when asked what
he had done the previous day, LH replied that he had been to
work but it was a terrible mess. The files had been lost and the
catalogue did not make sense any more. The worse thing, he
said, was that others could not really help him. The information
was gone, he could not retrieve it. On another occasion, when
asked if he remembered who the examiner was he replied as
follows: “Yes, I had to do a promotion in Durham University
but the material was complicated and they brought in this
Greek lass. I was showing her the catalogue, everybody else
was laughing but to their surprise she understood. She is the
one who introduced us, isn’t she?” [at the time the examiner,
who is Greek, was based at Durham University. LH was never
involved in business with the University].
Neuropsychological evaluation
LH’s performance of standardised neuropsychological tests is
summarised in Tables 1 and 2. His IQ appeared moderately
deteriorated, while his verbal and visual anterograde memory
showed marked deterioration. LH made a few intrusions,
mainly in the delayed recall of auditory tests. His recollection

Fig. 1. CT scan images performed 10 days post-surgery demonstrate evidence of left frontal craniotomy. There is a large acute infarction
within the left frontal lobe, including both dorsolateral and ventromedial prefrontal cortex. In addition, there is a smaller haematoma within
the posterior aspect of the right frontal lobe and a small residual haematoma in the depth of the anterior interhemispheric fissure/septum
pellucidum. Residual subarachnoid blood is noted within the mid line frontal sulci and over the convexity mainly on the left. There is soft
tissue swelling within the scalp tissues overlying the left frontal craniotomy.
 8 A. FOTOPOULOU ET AL.
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Table 1. Neuropsychological evaluation of LH’s intellectual and memory abilities

Test Score Age-adjusted level

Intelligence: WAIS-III Index scores

Verbal IQ score 93 Average
Performance IQ score 53 Extremely low
Verbal comprehension 105 Average
Perceptual organization 54 Extremely low
Working memory 75 Borderline
Processing speed 57 Extremely low
Full scale IQ score 73 Borderline
WTAR estimated IQ 92
Memory tests
WMS III Index scores
Auditory immediate memory 59 Extremely low
Visual immediate memory 88 Low Average
Immediate memory 67 Extremely low
Auditory delayed 58 Extremely low
Visual delayed 75 Borderline
Auditory recognition delayed 55 Extremely low
General memory 57 Extremely low
Working memory 105 Average
Rey complex figure Raw scores
Copy 33/36 Normal
Immediate recall 9 Impaired
Delayed recall 7 Impaired
AMI Raw scores
Personal semantic memory:
Childhood 14/21 Borderline
Early adult life 12/21 Definitely abnormal
Recent life 9/21 Definitely abnormal
Total 35/63 Definitely abnormal
Autobiographical incidents:
Childhood 5/9 Borderline
Early adult life 4/9 Probably abnormal
Recent life 1/9 Definitely abnormal
Total 10/27 Definitely abnormal
Other tests
Mood: HADS
Anxiety score 10 Borderline (8–10)
Depression score 10 Borderline (8–10)
Semantic abilities
Pyramids and palm trees test 88.4% Correct rate 98.5%
Orientation
WMS-III orientation sub-test 43% Correct rate 5th percentile
RBMT-E orientation subtest 10.5/14 Profile score 1

of his own past was poor, particularly for recent years (Auto-
biographical Memory Interview; Kopelman et al., 1990). His
performance on this task was also contaminated by confabu-
lation and perseveration. LH did not appear aware of these
difficulties nor of the lack of coherence in his memories.
More generally, LH appeared as densely anosognosic, in that
he had limited awareness of his cognitive difficulties. Occa-
sionally, he acknowledged some problem, but minimised its
importance or its self-relevance by confabulating, e.g. “Yes, I
do find that over the last three four weeks I am exhausted all
the time. But everybody has it. It’s a bug”. He also denied the
consequences of his impairments such as his inability to live
independently or manage his finances. In order to answer
such questions he used information and self-values from his
premorbid life. For example, he frequently referred to his
duties and responsibilities as a local area manager in order to
demonstrate what he thought were his current intact abilities.
His performance was impaired on most tests of executive func-
tions but there were some exceptions, in particular the Cognitive
Estimates Test (Shallice and Evans, 1987) and the letter fluency
task (Delis et al., 2001; D-KEFS) (see Table 2). LH clearly
underestimated his executive difficulties relative to the beliefs of

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Table 2. LH’s performance on tests of executive functions
Test
Hayling test
DEX Questionnaire (BADS)
LH self-report ratings
Staff ratings
Relative ratings
Cognitive estimates
D-KEFS
Trail making
Condition 4: switching
Total errors in condition 4
Contrasts 4 vs: motor speed
Contrasts 4 vs:
visual scanning
Vs: combined measure of
reading
Verbal fluency
Letter
Category
Switching
Switching accuracy
Set-loss errors
Repetition errors
Design fluency
Composite score
Switching
Switching vs combined
Repetition designs
Percent design accuracy
Color-word interference
Naming and reading
Inhibition
Inhibition/Switching
Inhibition errors
Inhibition/Switching errors
Sorting
Free sorting correct sorts
Free sorting
description score
Repeated sorts
20 Questions
Initial abstraction
Total questions asked
Weighted
achievement score
Word content
Total consecutively correct
Tower
Total achievement score
Mean first-move time
Total rule violations
Rule-violations-per-item ratio
Proverb free inquiry
SELF-ENHANCING CONFABULATION 9
his relatives and staff as illustrated by his scores in the Dysexecu-
tive Syndrome Questionnaire (Wilson et al., 1996; BADS).
Age-adjusted LH’s mood ranged from apathy to occasional, sudden epi-
Score level sodes of agitation. Despite his apparent apathy, his depression
SS 1 Impaired and anxiety scores were marginal on a self-report mood assess-
ment questionnaire (Zigmont and Snaith, 1983; HADS, Table 1).
M 1.9 (SD 1.4) Minimisation Care staff reported that LH was unmotivated to participate in
M 2.7 (SD 1.1) rehabilitation activities, a stance which was embedded in con-
M 2.7 (SD 0.9) fabulatory belief systems. For instance, he claimed he was in a
Error score: 5 Normal holiday resort in Australia and he treated the staff accordingly.
SS (age-adjusted) Normative During assessment, LH often spontaneously described
mean (SD) lengthy fictitious events that included fragments of real experi-
ences, as well as elements of his thoughts and inner needs. For
1 10 (SD 3) instance, in sessions preceding his lunch he often mentioned his
3 10 (SD 3) hunger and then immediately went on to describe relevant false
1 10 (SD 3) events such as the opening of a new canteen in the area. On
3 10 (SD 3) another occasion he began to treat the examiner as a waitress and
asked what was on the day’s menu. When the examiner ques-
8 10 (SD 3) tioned him, he was often either hungry, or thirsty. In the face of
such pressing needs, LH apparently employed elements of past
self-representations to contextualise them. For example, in want-
9 10 (SD 3)
1 10 (SD 3) ing to leave the ward, he often claimed he had an important busi-
1 10 (SD 3) ness meeting to attend, or that his car was parked just outside and
1 10 (SD 3) he had to move it immediately or he would be fined.
4 10 (SD 3) It thus appeared clinically that LH produced mostly wishful
9 10 (SD 3) and self-enhancing confabulations. In order to substantiate this
clinical impression, two experimental studies were conducted.
8 10 (SD 3)
6 10 (SD 3)
Experimental investigations
7 10 (SD 3)
6 10 (SD 3)
Control participants
12 10 (SD 3) A control group of five neurologically healthy adults were
10 10 (SD 3) recruited. These were males with approximately the same age
14 10 (SD 3) and educational ability as LH, mean age of 57.8 (2.2), ranging
1 10 (SD 3) from 56 to 61 years, and mean education of 13.6 (2.3) years.
1 10 (SD 3) Written consent was obtained for all participants. The study
was approved by the local NHS Trust’s Ethical Committee.
6 10 (SD 3)
5 10 (SD 3)
1 10 (SD 3) Study 1: True and false self-defining memories
The main aim of this experiment was to examine whether the
7 10 (SD 3) specific confabulations constructed by our patient portrayed a
7 10 (SD 3) self-representation that was more positive than that depicted
8 10 (SD 3)
in his true memories. “Self-representation” was defined as
the knowledge one has about oneself, e.g. the events of one’s
2 10 (SD 3) life history, character traits, physical appearance, relation-
ships with other people, role in society etc.
6 10 (SD 3)
12 10 (SD 3)
9 (percentile Materials and procedures
rank)
We used a modified version of the McAdam’s (1985) life story
7 10 (SD 3)
4 10 (SD 3)
technique to elicit self-defining autobiographical memories
(McAdams et al., 2001). LH and the controls were asked to
 10 A. FOTOPOULOU ET AL.
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describe 12 self-defining events, including a particularly pleasant
experience (high point), a sad experience (low point), a turning
point in their life, their earliest memory, an important childhood
event, an important adulthood event, a recent important event, an
important event from any lifetime period, a memory that dis-
played something stable about the self, a decision-making mem-
ory, a memory of an important moral dilemma and a goal
memory. The resulting memory protocols were coded for their
content by two raters, blind to both the hypothesis and the groups
of the study, who were previously trained in the coding system
(Fotopoulou, 2005). They were given the protocols in random
order, as “protocols of true and false memories produced in psy-
chological interviews” with the first author. Separate interviews
were held with participants’ relatives and staff, who provided cor-
roborative information for every memory protocol.
Statements to be coded were sequences of phrases or sen-
tences that described a single thematic content. All statements
included in the confabulation protocols were coded, as it was
considered arbitrary to separate accurate statements from the
“confabulated” context in which they were recalled. Multiple
memories were also scored as it was not always possible to sepa-
rate their limits (see Levine et al., 2002, for an alternative
approach), and more generally we felt that given the complexity
and often semantic obscurity of confabulatory protocols, the
experimenters should not apply arbitrary criteria of exclusion but
rather allow the patient to determine the limits of his memories.
This of course could lead to differences between controls and
LH, but in this way these differences could be observed rather
than masked by experimentally induced uniformity (see also
Fotopoulou et al., 2004). For the same reasons, repetitions (per-
serverations) of statements were scored only once, but only
when obvious, or when acknowledged by the patient himself.
Two main categories were coded. These were (1) Overall
valence of memory and (2) Self-representation valence.
1.The overall emotional valence of each accurate or confabu-
latory account was measured on a five-point scale: 1 =
negative; 2 = emotional shift from positive to negative;
3 = neutral; 4 = emotional shift from negative to positive;
5 = positive. Emotional shift ratings were included as
investigations into autobiographical memory have shown
that such shifts are both frequent in personal narratives
and central to the formation and expression of one’s self-
representation and identity (for review see McAdams,
2001). These shifts were defined as “explicit transforma-
tions in the story from a decidedly negative affect state to
a decidedly positive-affect state” and vice versa (McAd-
ams et al., 2001). The original affect state had to be
explicit and the transformation could include either a
change to an affect state of the opposite valence, or the
production of an outcome with the opposite affect state.
For example, LH described that as a young child he was
very attached to his mother, not very strong-willed and
picked upon by his classmates. Following her death he
felt totally devastated but his sorrow helped him build a
strong personality and he progressively gained the admi-
ration of his class mates.
2.Self-representation rating included any statements explic-
itly providing information about the “self” and its position
in interpersonal relations (e.g. “I never had any high
sights”, or “I always gave my family everything”). In this
scoring category the self-representation could be scored
with regard to its emotional valence, i.e. negative, posi-
tive, or neutral (neutral, ambivalent or hard to evaluate)
and its agency, i.e. “self” as active/responsible (e.g. one
who cares for others) or “other” as active/responsible and
“self” as passive (e.g. one who is supported by others).
Study 2: Intentional confabulation
The aim of these studies was to examine whether LH’s confabu-
lations were the result of his intentional efforts to fill in memory
gaps, or comply with the suggestions of the examiner.
Confabulation and gap-filling
In order to assess whether LH’s confabulation was explicable
by a gap-filling tendency, the “Dalla Barba Confabulation
Battery” (1993) was administered. This test consists of six
subsections of questions (see Figure 2). The last two sections
include questions—the answers to which are generally
unknown, e.g. semantic memory: “What was the profession
of Marilyn Monroe’s father?”, episodic memory: “How did
you spend Christmas Day on 1985?”. If LH’s confabulations
were explained by a gap-filling tendency more confabula-
tions should be produced when these questions were posed
than in the other sections. Answers were recorded verbatim
and confabulations were scored using Dalla Barba’s (1993)
criteria.
Fig. 2. Percentage of confabulations by LH in the confabulation battery.
Note: Memory sections: Personal Sem, Personal Semantic; Orientation,
Orientation in Time and Place; General Sem, General Semantic; DK
Semantic, Do not know Semantic; DK Episodic, Do not know Episodic.

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Confabulation and suggestibility
The Gudjonsson Suggestibility Scale (GSS1) (1997) was
used to assess LH’s potential tendency to provide answers
according to external suggestion. This scale comprises a
narrative paragraph, which the participants have to recall.
Following this, 20 questions related to the story (15 sugges-
tive [i.e. misleading] and five non-suggestive [i.e. based on
the story]) are asked. The 20 questions were then asked a sec-
ond time, following clear negative feedback (the patient is
explicitly told that he gave many wrong answers the first
time), and positive answers on these questions are scored as
“Yield 1” (giving in to suggestive questions) “Yield 2” (giv-
ing in to suggestive questions following negative feedback),
“Shift” (number of times subjects change their answers
following negative feedback) and “Total Suggestibility”
(Combined scores of Yield 1 and Shift). Gudjonsson’s (1997)
scoring criteria were followed.
Results
Study 1
Controls produced 12 accurate memories each (as defined by
corroborative information), although some of their memories
were less coherent and specific than others. LH produced
seven accurate memories and five confabulations. In order to
compare the accurate accounts produced by LH during the
interview with an equal number of confabulatory narratives,
the first two spontaneous self-referential confabulations pro-
duced by LH in the same week were corroborated and
included in the comparison. The two independent raters
agreed on 92% of the selected items to be coded and 98% of
the specific classifications made. Their remaining differences
were resolved by discussion.
Overall valence
The overall valence of the memories of the control partici-
pants showed a mild positive bias (M = 3.4; SD = 0.1),
while LH’s accurate memories (M = 2.7) were signifi-
cantly more negative (t = 6.4, p < 0.01; Crawford and
Howell, 1998). In contrast, five out of LH’s seven confab-
ulations were rated as pleasant, or as ending in pleasant
conditions for LH; their mean valence (M = 3.9) was sig-
nificantly more positive than that of the controls (t = 4.6,
p < 0.01; Crawford and Howell, 1998). Moreover, it should
be noted that LH’s two negative confabulations referred
mostly to fabricated reasons for his admission. Although the
confabulated memories are unpleasant as scored, they are
actually “pleasant”, if one considers the “reality” to which
they correspond, i.e. the true reasons for admission. For
example, the patient stated that he was sent to the hospital
because he had some pens to deliver for the “morning art
session” and that he has been “in their hands ever since”.
SELF-ENHANCING CONFABULATION 11
Valence of self-representation
There was an overall difference between the amount of self-
representations mentioned by controls and that mentioned by
LH in his confabulations and his true memories (χ2 (df = 2) =
8.1, p < 0.05). Non-parametric post hoc tests (Bonferroni
corrected) revealed that the number of self-representations
mentioned by LH in his confabulations (56 different refer-
ences) were significantly greater than the number of self-
representations mentioned by the controls (41 representations on
average across 12 memories; Z = 2.6, p < 0.01). Confidence
limits on this result were calculated using a t-test calculation
developed specifically for case studies (t = 4.4, p < 0.05; Esti-
mated percentage of normal population falling below individ-
ual’s score = 99.42%; 95% lower confidence limit on the
percentage = 93.70%; Crawford and Howell, 1998). No other
difference was significant (p values > 0.1). This frequent
self-referencing in LH’s confabulations may relate to the fact
that the latter included only a few contextual details of the
narrated events and instead centred on specific ideas he
apparently wanted to convey about himself (see Example
below). The described events and facts appeared as a random
background to the self-related ideas on which LH focussed.
In addition, unlike controls, who narrated social occasions
such as relatives’ weddings and the birth of children, etc., he
never placed the focus of a memory on anybody but himself.
His confabulations further seemed to convey a preoccupa-
tion to describe himself in positive terms. Indeed, LH’s con-
fabulations contained significantly more positive than negative,
or neutral self-representations than his true memories (χ2
(df = 2) = 13.9, p < 0.001), and marginally (not reaching
significance) more positive than negative, or neutral self-
representations than the true memories of the controls (χ2
(df = 2) = 4.2, p = 0.06). Most of these self-enhancing themes
related to his determination and achievements in life, his rec-
ognised authority and his superior intellectual abilities.
Although these values featured in his true memories (see
below), in his confabulations they were retrieved more fre-
quently and in irrelevant context. Moreover, as his relatives
also noted, these positive values were grossly exaggerated
and had overshadowed other, less positive, components of his
premorbid self-representation. Interestingly, LH rarely
expressed positive feelings toward others, such as sympathy,
concern, or longing, in his true or false memories. Finally,
similarly to controls, LH focused more on active and respon-
sible self-representations (e.g. achieving goals, loving or mis-
behaving towards others) than passive ones (e.g. being loved
or hurt by others). These findings are summarised in Table 3.
In his confabulations LH described himself as “superior”
to others and he appeared frustrated at others’ “lower intellec-
tual” or other abilities and he repeatedly described how he
had “set the record straight”, had established his authority
and had achieved what he wanted once he had taken control
of the situation. He persistently misused, misinterpreted and
wrongly combined events from his past to contextualise these
self-congratulatory thoughts and feelings. The example
 12 A. FOTOPOULOU ET AL.
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Table 3. Percentages of self-representations in true memories and confabulations
LH’s confabulations
Agency Valence %1
Self Positive 42.85
Negative 28.65
Neutral 5.35
Other Positive 8.9
Negative 12.5
Neutral 1.8
1
Percentage of the total number of self-representation statements in LH’s confabulations.
2
Percentage of the total number of self-representation statements in LH’s true memories.
3
Percentage of the total number of self-representation statements in controls’ true memories.
4
Significant differences compared with controls (χ2 (2)=9.9, p < 0.01).
5
Significant differences compared with LH’s true memories, (χ2 (2)=13.9, p < 0.001).
below is characteristic of both his positive self-representation
and the disorganisation of his recall.
Confabulation Example
Decision-Making Event: There’s all sorts of things.
Important decisions … I elected which way I wanted to go in
life, and I’ve done it. And it’s proved out to be a bit of a has-
sle. Because these are people who aren’t particularly bright. I
mean I don’t think it is my arrogance, they might be, but I
don’t think they’re as bright as me … get above me. And,
they come up with the most ridiculous things. And since me
last birthday I thought, ah, I’ve really had enough of this. So I
started to be a lot more honest with people and tell them what
I think of what they’re doing. But actually, they all say how
grateful they are I’ve done that. [Hm.] Because they’re so
inexperienced. The danger comes when they think they are
experienced and they want to do the same bloody thing. [So
do you remember any more details about the day you took
such a decision? What happened?] Oh … to be totally honest?
Fairly recently, actually. Probably about ten years ago. But, in
the first place, to be devious and do the job. It’d be … proba-
bly right at the end of me teens. About, sort of, 19 to 21, that
sort of area. Um, now … it’s a lot easier, but people abso-
lutely hate me for it. Because I regularly – well, they think
I’m kicking against the pricks. Telling them what I think of
their decisions. Because if they blew me out now, I could just
write a cheque and pay me mortgage off. The house is mine.
Um … and in the worst scenario you know, I could live. But,
the problem is, particularly when – what the hell is the com-
pany called? What were we before we became what we are
now? And I can’t remember what we’re called now, either.
I’ve never bothered to look at it. Um… see, that was a mess.
The company was a mess. It came so close to closing down, it
was just unbelievable. I think I told you it took the third tele-
phone call in one morning to stop the company being closed
down. Uh … (looks perplexed). [You were talking about the
decision you took to … interrupted by the patient:] It’s easier
to talk about the company, you see. Laughs. [I see].
[Corroboration Notes: LH’s hospitalisation coincides
with his “last birthday”. It is true that LH is more “outspo-
ken” since that time but this could hardly be described as
LH’s true memories Controls’ true memories
%2 %3
21.44 38.8 (SD 6.7)
40.54 24.4 (SD 6.4)
14.34 12.9 (SD 5.7)
7.1 9.8 (SD 7)
11.9 11.7 (SD 3.9)
4.7 2.3 (SD 2.5)
honesty and it was definitely not the result of his decision.
Some of his other associations have kernels of truth in them
but are hard to understand, for example his company was
indeed recently bought by another company and thus
changed name. His family is not aware of any other period
when he claimed he took the decision of becoming more hon-
est, or more critical of others]
In LH’s accurate memories he portrayed himself and his
relationship with others in more negative terms than the control
subjects did (χ2 (2) = 9.9, p < 0.01) (Table 3). However, it is
noteworthy that although LH remembered many unpleasant
events and described several negative self-representations in
his accurate memories, he typically ended his narration by
describing how he overcame the difficulties and how he bene-
fited from such experiences (“redemption narratives” see
McAdams et al., 2001). He gave similar answers to questions
about a sad event (how his mother’s early death made him
stronger, see above), an early adulthood event (how a first neg-
ative experience with a girl taught him a lesson), a moral
dilemma (how he took the right decision in dealing with a diffi-
cult moral situation in his family), and an event that shows self-
continuity (how he had become lazy because his intellectual
abilities had always been greater than those of others).
Study 2
The performance of LH and the control subjects across the sec-
tions of the Dalla Barba Confabulation Battery is summarised
in Figure 2. LH confabulated across all the sections of the bat-
tery; more often he confabulated when answering episodic
questions, orientation questions and “Don’t know” semantic
questions. Interestingly, LH confabulated less in episodic
“don’t know” questions and seemed to realise their difficulty.
The performance of LH and the control subjects on the
Suggestibility Scale is summarised in Table 4. As expected,
LH’s immediate recall scores were abnormal in comparison
with the means of the general population (Gudjonsson, 1997).
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Table 4. LH’s performance on the Suggestibility Scale

Intellectual disabilities
Suggestibility Scale GSS1 LH (percentile) General population norms sample (IQ 57–75)
Immediate recall 8 (5th) 21.3 (7.1) 7.3 (4.5)
Delayed recall – 19.5 (7.5) 5.9 (4.5)
Yield 1 9 (90th) 4.6 (3) 7.1 (4)
Yield 2 12 (90th) 5.6 (3.8) 8.5 (4.4)
Shift 5 (75th) 2.9 (2.5) 5.0 (3.6)
Total suggestibility 14 (90th) 7.5 (4.6) 12.1 (6.2)
Distortions (immediate) 1 1.15 (1.2) (GSS2)
Distortions (delayed) – 1.26 (1.8) (GSS2)
Fabrication (immediate) 1 0.4 (0.7) (GSS2)
Fabrication (delayed) – 0.5 (0.7) (GSS2)
Note: GSS1, Gudjonsson Suggestibility Scale Version 1; GSS2, Gudjonsson Suggestibility Scale Version 2.

His initial Yield scores were abnormally high (partly explica-
ble by his poor memory). His Shift score, which was 5,
(range for normal subjects 2.9; SD = 2, see Table 4) indicates
that negative feedback and repeated exposure to distracting
information had a limited influence on his answers. His Total
Suggestibility score was not within the normal range (>1 SD
and <2 SD of normal controls), but was within the range of
individuals with intellectual disabilities (IQ 57–75). Thus, his
scores on the Suggestibility measures indicate that his
responses to memory questions did “yield” to external sug-
gestion but not to the degree expected, as defined by the
available normative data for individuals with similar IQ level
and as expected given his memory deficits.
Discussion
This study examined whether the false memories constructed
by our patient would portray a representation of himself that
was more positive than the corresponding self-representation
depicted in his own real memories. Our findings confirmed
that LH referred to his self-representations more frequently
than in his accurate memories and significantly more fre-
quently than controls referred to themselves in their accurate
memories. Moreover, LH’s confabulations were more posi-
tive in overall valence and they included more self-enhancing
self-representations than his true memories. In a previous
case report we found that the content of spontaneous confab-
ulation often features a positive emotional bias (Fotopoulou
et al., 2004). The present study confirms this finding under
tighter experimental control and provides further details of
the nature of these self-related biases in confabulation. Spe-
cifically, LH’s confabulations seemed to portray a self-repre-
sentation which predominately relied on the exaggeration of
premorbid values of self-esteem, positive character traits and
professional competence. The latter were also present in his
accurate memories but to a lesser degree. These “positive”
features (Jackson, 1932) of the content of LH’s confabulations
could not be explained solely by his cognitive impairments.
The role of these impairments in producing confabulation, as
well as the role of conscious or unconscious motivational fac-
tors in shaping the content of LH’s specific confabulations,
are discussed further below.
Neurocognitive deficits
LH’s neuropsychological profile was characteristic of that
shown by most other confabulating patients (see Deluca,
2000; Johnson et al., 2000, for reviews). He showed severe
memory and executive functions impairment. The latter
included disinhibition, perseveration, and lack of flexibility,
abstraction and self-monitoring. This profile is consistent
with the “retrieval deficit” account of confabulation (e.g.
Burgess and Shallice, 1996; Moscovitch, and Melo, 1997). A
somewhat surprising finding was LH’s relatively good per-
formance on two tests of reasoning (Cognitive Estimates and
20 Questions Test) and one test of problem solving (Tower
Test). In some retrieval models, such functions have been
linked with more “bizarre” and “fantastic” forms of confabu-
lation (e.g. Burgess and Shallice, 1996). LH showed such
confabulations (e.g. his bizarre narratives about his reasons
for admission), yet he did not present with such deficits.
Moreover, LH showed reduced motivation and problematic
social conduct. This pattern is not uncommon and is associ-
ated with lesions of the ventromedial prefrontal cortex (e.g.
Bechara et al., 2000; Berlin et al., 2004), that receives its
blood supply from the anterior cerebral artery and associated
vessels. His confabulation was more frequent in the episodic
memory domain and in orientation questions, but was not
restricted to these domains (see also Dalla Barba et al., 1997;
Fotopoulou et al., 2004; Kopelman et al., 1997).
Self-enhancing content
LH retrieved fragments of previous memories and current
thoughts in a poorly organised, incoherent, and inconsistent
fashion (Conway and Fthenaki, 2000; Kopelman et al., 1997;
 14 A. FOTOPOULOU ET AL.
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Moscovitch and Melo, 1997). Nevertheless, the consistently
self-enhancing content observed in LH’s confabulations
could not be explained by a “retrieval deficit” account with-
out presupposing complementary emotional mechanisms (see
Fotopoulou et al., 2004, for further discussion). For example,
the Burgess and Shallice’s account of confabulation (1996)
could explain how the highly generic nature of self-related
themes may render them easier candidates for recollection
and thus increase their presence in the content of confabula-
tions (see also Conway, 2005; Dalla Barba et al., 1997;
Gilboa et al., 2006). However, these models cannot explain
why such self-reference is positive and self-enhancing unless
they refer to normal or exaggerated emotional influences, as
these are observed in other studies of normal autobiographi-
cal memory (see Conway, 2005, for review; see also below).
Alternatively, the observed emotional bias could be accounted
for by explanations which propose that confabulation represents
the conscious attempt to hide memory gaps, and fill them in with
information constructed ad hoc, or with information which might
satisfy the suggestions of the examiner (see Berlyne, 1972; Whit-
lock, 1981, for reviews). However, LH showed only minimal
confabulation in episodic memory questions for which he did not
know the answer (see also Mercer et al., 1977; Moscovitch and
Melo, 1997; Schnider et al., 1996). Additionally, he showed only
mild suggestibility, consistent with his intellectual and memory
difficulties. These results are also consistent with observations of
his spontaneous behaviour. LH’s confabulations often appeared
independently of leading efforts and prompts, i.e. they were spon-
taneous rather than provoked (Kopelman, 1987). LH was
unaware of his cognitive difficulties and thus his confabulations
could not represent conscious attempts to compensate for mem-
ory loss. In addition, they were at times accompanied by corre-
sponding actions or intentions for action (see also Schnider et al.,
1996). Also, both LH and his relatives described his premorbid
personality as highly assertive and rather resistant to suggestion.
It is therefore unlikely that gap-filling and suggestion had a pri-
mary causative role in LH’s confabulations. More likely these
factors contributed only to the production of secondary confabu-
lations, which aimed to provide support for his original confabu-
lations (see also Moscovitch, 1989).
We propose that LH’s self-enhancing confabulations can be
best explained as the product of exaggerated motivational influ-
ences on autobiographical memory construction. Autobiographi-
cal memory allows individuals to construct an organised and
continuous sense of self in time (e.g. Conway, 2005; McAdams,
2001; Neisser, 1988; Nelson, 2003). These self-representations
are formed according to both cognitive abilities and motivational
factors (Conway, 2005). When brain dysfunction and cognitive
deficits impair the ability to form autobiographical memories,
self-identity and the sense of self-continuity are also compro-
mised (see also Conway and Fthenaki, 2000). The self-represen-
tation of confabulating patients is no longer constrained by true
self-defining autobiographical events (Conway and Tacchi,
1996; Fotopoulou et al., 2004; see also Johnson and Raye, 2000,
for discussion), or the realistic appreciation of their current
condition (see Schnider, 2003). LH’s case further suggests
that against the background of memory and executive disorgani-
sation, his self-representation was constructed under the exag-
gerated influence of motivational factors, particularly premorbid
self-regard, previous strategies of coping with stressful situations
and present needs and goals. LH appeared to unconsciously
combine self-enhancing elements of his autobiography and parts
of his wishful thoughts to create a highly self-congratulatory
memory collage, albeit incoherent and falsely rooted in reality.
Thus, it appears that motivational factors continue to have
an influence on autobiographical memory construction. They
may even be exaggerated because of the cognitive dysfunction
that arises due to damage to the ventromedial prefrontal cortex
(see Conway and Fthenaki, 2000; Johnson et al., 2000), as well
as because of the unpleasant situation in which patients find
themselves after brain injury. Indeed, given LH’s devastating
brain damage, motivational mechanisms of self-esteem
enhancement may have become more pertinent. It should be
noted that LH’s accurate memories were more negative than
his confabulatory ones, which in turn were more positive than
those of the controls, even though they contained only margin-
ally more positive self-representations than those of the con-
trols. These findings suggest that he may have been more
affected by his predicament than it appeared. In other words,
his accurate memories may have represented successful and
mood-congruent retrieval attempts (see also HADS results),
while the content of his confabulations may have been under
the influence of positive self-serving emotions, which were not
founded in current reality but which permitted him to “escape”
the unpleasantness of his accurate self-representation by
retrieving pleasant, yet false, versions of it. Often this seemed
to take place by providing pleasant but false endings and inter-
pretations to unpleasant narratives, or by placing self-enhanc-
ing ideas and thoughts in an irrelevant context.
Interestingly, LH’s pre-morbid behaviour suggested that
he had always been someone who has tended to inflate his
abilities and importance, particularly when undergoing
stressful and self-threatening periods. In future studies it will
be interesting to also assess non-confabulating patients with
ventromedial frontal lesions in order to specify the exact con-
tribution of these lesions to self-enhancing confabulation ver-
sus that of the premorbid personality and the coping strategies
of patients. Although previous studies have shown that fron-
tal non-confabulating patients show affective and behavioural
disinhibition, as well as disorganised retrieval, perhaps future
studies can explain why confabulating patients with similar
lesions not only retrieve and narrate false self-enhancing
events, but also accept them as part of their autobiography and
experience them with similar recollective quality to their true
memories (Ciaramelli et al., 2006; Dalla Barba, 1993). Based
on this case-study, we argue that confabulations are constructed
according to an increase in motivational self-enhancement
needs and an impairment in the executive control of memory,
which allows these motivational influences to dominate mem-
ory formation and create self-congratulatory false memories.
In conclusion, these findings suggest that the normal ten-
dency to construct self-enhancing autobiographical memories

Downloaded By: [Kings College London] At: 10:03 23 April 2007
may be exaggerated in confabulating patients. This is thought
to be caused by the memory and executive dysfunction that
mediates the construction of confabulations in the first place.
In other words, confabulations could be described with refer-
ence to what is missing, that is, the appreciation of current real-
ity and the appropriately organised retrieval of the past. Most
crucially, they could also be described by what remains, that is,
the dominance of premorbid self-values and current inner
drives and goals. The case of LH highlights the dynamic inter-
action of cognition and emotion in memory construction. Brain
damage that affects one’s autobiographical memory, and hence
the construction of one’s self-representation, is likely to have
both cognitive and motivational consequences.
Original manuscript received 29 June 2006
Revised manuscript accepted 6 December 2006
First published online 19 February 2007
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